Fillable Public Service Employment Certification Form (South Puget Sound Community College)

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Public Service Employment Certification Form (South Puget Sound Community College)

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PSLF ECF
PUBLIC SERVICE LOAN FORGIVENESS (PSLF):
EMPLOYMENT CERTIFICATION FORM
William D. Ford Federal Direct Loan (Direct Loan) Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on
any accompanying document is subject to penalties that may include fines, imprisonment, or both, under
the U.S. Criminal Code and 20 U.S.C. 1097.
OMB No. 1845-0110
Form Approved
Exp. Date 5/31/2020
PSECF - XBCR
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City State Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)
Date of Birth
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATION
Before signing, carefully read the entire form. For more information on PSLF, visit StudentAid.gov/publicservice
.
I authorize:
1. My employer or other entity having records about the employment that is the basis of my request to make information
from those records available to the U. S. Department of Education (the Department) or its agents or contractors.
2. The entity to which I submit this request and its agents to contact me regarding my request or my loans at any cellular
telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or
prerecorded voice or text messages.
I understand that:
1. To qualify for PSLF, I must make 120 qualifying payments on my Direct Loans while employed full-time by a qualifying
employer or employers. Neither the 120 qualifying payments nor the employment have to be consecutive.
2. To qualify for PSLF, I must be employed full-time by a qualifying employer when I apply for and receive PSLF.
3. If I qualify for forgiveness, only the remaining balance on my Direct Loans will be forgiven.
4. By submitting this form, my student loan(s) held by the Department will be transferred to FedLoan Servicing.
5. The Department may request supplemental documentation substantiating my employment.
6. The Department will notify me in writing or electronically of the number of qualifying payments I have made while
employed full-time by a qualifying employer and how many more I must make before I am eligible to apply for PSLF.
7. I will be notified if the form that I submit is incomplete, or if my employment or payments do not qualify for PSLF, why
the determination was made, and the steps I need to take to correct the form or make qualifying payments.
The Department will retain this certification form until I submit my application for forgiveness.8.
I certify that all of the information I have provided on this form and in any accompanying document is true, complete, and
correct to the best of my knowledge and belief.
Check this box if you cannot obtain certification from your employer because the organization is closed or because the
organization has refused to certify your employment. The Department will follow up to assist you in getting
documentation of your employment. Complete Section 3, but do not complete Section 4.
Date
Borrower's Signature
Page 1 of 6
Borrower Name Borrower SSN
SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
1.
Employer Name:
2.
Federal Employer Identification Number (FEIN)
Your employer's Federal EIN may be found on your
Wage and Tax Statement (W-2).
3.
Employer Address:
4.
Employer Website (if any):
5.
Employment Begin Date:
6.
Employment End Date:
OR
Still Employed
7. Employment Status:
Full-Time Part-Time
8.
Hours Per Week (Average)
Include vacation, leave time, or any leave taken
under the Family Medical Leave Act of 1993. If your
employer is a 501(c)(3) or a not-for-profit organization,
do not include any hours you spent on religious
instruction, worship services, or proselytizing.
9. Is your employer a governmental organization?
A governmental organization is a Federal, State,
local, or Tribal government organization, agency, or
entity, a public child or family service agency, a Tribal
college or university, or the Peace Corps or
AmeriCorps.
Yes - Skip to Section 4.
No - Continue to Item 10.
10.
Is your employer tax-exempt under Section 501(c)(3)
of the Internal Revenue Code (IRC)?
If your employer is tax-exempt under another
subsection of 501(c) of the IRC, such as 501(c)(4) or
501(c)(6), check "No" to this question.
Yes - Skip to Section 4.
No - Continue to Item 11.
11.
Is your employer a not-for-profit organization that is
not tax-exempt under Section 501(c)(3) of the Internal
Revenue Code?
Yes - Continue to Item 12.
No - Your employer does not qualify.
12.
Is your employer a partisan political organization or a
labor union?
Yes - Your employer does not qualify.
No - Continue to Item 13.
13.
Which of the following services does your employer
provide as its primary purpose? Check all that apply
and then continue to Section 4. If you you check
"None of the above", do not submit this form.
Emergency management
Military service (See Section 6)
Public safety
Law enforcement
Public interest legal services (See Section 6)
Early childhood education (See Section 6)
Public service for individuals with disabilities
Public service for the elderly
Public health (See Section 6)
Public education (See Section 6)
Public library services
School library services
Other school-based services
None of the above - the employer does not
qualify.
SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
By signing, I certify (1) that the information in Section 3 is true, complete, and correct to the best of my knowledge and
belief, (2) that I am an authorized official (see Section 6) of the organization named in Section 3, and (3) that the borrower
named in Section 1 is or was an employee of the organization named in Section 3.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Official's Name
Official's Title
Official's Phone
Official's Email
Authorized Official's Signature
Date
Page 2 of 6
SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
If you have made 120 qualifying payments and the certification in Sections 3 and 4 does not cover all of those payments, you
must provide information about other employers by submitting one copy of Sections 1 and 2 (Page 1), and one copy of
Sections 3 and 4 (Page 2) per employer. When completing this form, type or print using dark ink. Enter dates as month-day-
year (mm-dd-yyyy). Use only numbers. Example: March 14, 2016 = 03-14-2016. For more information about PSLF and how to
use this form, visit StudentAid.gov/publicservice
. Return the completed form to the address shown in Section 7.
SECTION 6: DEFINITIONS
Qualifying payments are separate, on-time, full monthly
payments made on an eligible loan after October 1, 2007
under a qualifying repayment plan while employed full-time
by a qualifying employer.
An on-time payment is a payment made no more than
15 days after the due date for the payment.
Eligible loans are loans made under the William D. Ford
Federal Direct Loan (Direct Loan) Program that are not in
default.
Qualifying repayment plans include the Revised Pay As
You Earn (REPAYE) plan, the Pay As You Earn (PAYE) plan,
the Income-Based Repayment (IBR) plan, the Income-
Contingent Repayment (ICR) plan, the Standard Repayment
plan with a maximum 10-year repayment period, and any
other Direct Loan repayment plan if payments are at least
equal to the monthly payment amount that would be
required under the Standard Repayment plan with a 10-year
repayment period.
An employee means an individual who is hired and paid
by the qualifying employer.
Full-time means working for one or more qualifying
employers for the greater of: (1) An annual average of at
least 30 hours per week or, for a contractual or employment
period of at least 8 months, an average of 30 hours per
week; or (2) Unless the qualifying employment is with two
or more employers, the number of hours the employer
considers full time.
An authorized official is an official of a qualifying
employer who has access to the borrower's employment or
service records and is authorized by the employer to certify
the employment status of the organization's employees or
former employees, or the service of AmeriCorps or Peace
Corps volunteers.
Early childhood education includes licensed or
regulated child care, Head Start, and State funded pre-
kindergarten.
Law enforcement means crime prevention, control or
reduction of crime, or the enforcement of criminal law.
Military service means service on behalf of the U. S.
Armed Forces or the National Guard.
Public education includes services that provide
educational enrichment or support directly to students or
their families in a school or a school-like setting.
Public interest legal services refers to legal services
that are funded in whole or in part by a local, State, Federal,
or Tribal government.
Public health includes nurses, nurse practitioners,
nurses in a clinical setting, and full-time professionals
engaged in health care practitioner occupations and
health
support occupations, as such terms are defined by the
Bureau of Labor Statistics.
QUALIFYING PAYMENT DEFINITIONS
QUALIFYING EMPLOYMENT DEFINITIONS
A Qualifying employer includes the government, a not-
for-profit organization that is tax-exempt under Section
501(c)(3) of the Internal Revenue Code, or a private not-for-
profit organization that provides certain public services.
Serving in an AmeriCorps or Peace Corps position is also
qualifying employment.
Government includes a Federal, State, local or Tribal
government organization, agency or entity; a public child or
family service agency; or a Tribal college or university.
A private not-for-profit organization is an
organization that is not organized for profit, is not a labor
union, is not a partisan political organization, and provides
at least one of the following public services as its primary
purpose: (1) emergency management, (2) military service,
(3) public safety, (4) law enforcement, (5) public interest
legal services, (6) early childhood education, (7) public
service for individuals with disabilities and the elderly, (8)
public health, (9) public education, (10) public library
services, (11) school library services, or (12) other school-
based services.
AmeriCorps position means a position approved by the
Corporation for National and Community Service under
Section 123 of the National and Community Service Act of
1990 (42 U.S.C. 12573).
Peace Corps position means a full-time assignment
under the Peace Corps Act as provided for under 22 U.S.C.
2504.
QUALIFYING EMPLOYMENT DEFINITIONS (CONTINUED)
Page 3 of 6
A forbearance is a period during which you are allowed
to postpone making payments temporarily, allowed an
extension of time for making payments, or temporarily
allowed to make smaller payments than scheduled. A
forbearance can be a mandatory forbearance, meaning that
your loan holder must grant the forbearance if you qualify
for the forbearance and supply all supporting
documentation. A forbearance can also be a discretionary
forbearance, meaning that your loan holder may grant the
forbearance, but is not required to do so.
OTHER DEFINITIONS
SECTION 7: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to:
Mail to: U.S. Department of Education, FedLoan Servicing,
P.O. Box 69184, Harrisburg, PA 17106-9184.
Fax to: 717-720-1628.
Upload to: MyFedLoan.org/FileUpload
, if FedLoan
Servicing is already your servicer.
If you need help completing this form, call:
Domestic: 855-265-4038.
International: 717-720-1985.
TTY: dial 711, then enter 800-699-2908.
Website: MyFedLoan.org.
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF
You may receive loan forgiveness under this program only
after you have made 120 qualifying payments (see
"Payment Eligibility") on eligible loans (see "Loan Eligibility"
on page 5) while working full-time in qualifying
employment (see "Employment Eligibility" on page 5).
PAYMENT ELIGIBILITY
To receive PSLF, you must make 120 on-time, full,
scheduled, separate monthly payments on your Direct Loans
under a qualifying repayment plan after October 1, 2007.
On-time payments are those that are received by your
servicer no later than 15 days after the scheduled payment
due date.
Full payments are payments on your Direct Loan in an
amount that equals or exceeds the amount you are required
to pay each month under your repayment schedule. If you
make a payment that is less than what you are required to
pay for that month, that month's payment will not count as
one of the required 120 qualifying payments. If you make
multiple, partial payments in a month and the total of those
partial payments equals or exceeds the required full
monthly payment amount, those payments will count as
one qualifying payment.
Scheduled payments are those that are made while you
are in repayment. They do not include payments made while
your loans are in an in-school or grace status, or in a
deferment or forbearance period.
You must make separate monthly payments. Except as
explained below, lump sum payments or payments you
make as advance payments for future months do not count
as more than one qualifying payment. If you want to pay
more than your scheduled monthly payment amount, follow
the instructions on your bill to let your servicer know that
your payment is not intended to cover future installments.
Otherwise, you may not receive credit for future qualifying
payments.
If you were an AmeriCorps or Peace Corps volunteer, you
may receive credit for making qualifying payments if you
make a lump sum payment by using all or part of a Segal
Education Award or Peace Corps transition payment.
You may also receive credit for qualifying payments if a
lump sum payment is made on your behalf through a
student loan repayment program administered by the U.S.
Department of Defense (DOD).
If you make a lump sum payment by using an
AmeriCorps Segal Education Award or a Peace Corps
transition payment, or if a lump sum payment is made on
your behalf through a DOD student loan repayment
program, the Department will give you credit for qualifying
payments equal to the lesser of (1) the number of payments
resulting after dividing the amount of the lump sum
payment by the monthly payment amount you would have
made under one of the qualifying repayment plans listed
below; or (2) 12 payments.
If you make an eligible lump sum payment using a Peace
Corps transition payment, you must do so within 6 months
of the Employment End Date, as reported in Section 3.
You may only use an AmeriCorps Segal Education Award
or Peace Corps transition payment one time to receive
credit for more than one qualifying payment towards PSLF.
However, lump sum payments made on your behalf under a
DOD student loan repayment program may be counted as
up to 12 qualifying payments for each year that a lump sum
payment is made.
Your payments must be made under a qualifying
repayment plan. Qualifying repayment plans include the
REPAYE plan, the PAYE plan, the IBR plan, the ICR plan, the
10-Year Standard Repayment plan, or any other Direct Loan
repayment plan, but only payments that are at least equal to
the monthly payment amount that would be required under
the10-Year Standard Repayment plan.
Though repayment plans other than the REPAYE, PAYE,
IBR, and ICR plans are qualifying repayment plans for PSLF,
you must enter REPAYE, PAYE, IBR, or ICR to have a
remaining balance to forgive after becoming eligible for
PSLF. Otherwise, your loans will be fully repaid within 10
years. To apply for these plans, visit StudentLoans.gov
.
IMPORTANT: The Standard Repayment Plan for Direct
Consolidation Loans made on or after July 1, 2006 has
repayment periods that range from 10 to 30 years. Monthly
payments you make under this plan are qualifying payments
only if the repayment period is 10 years, which would be the
case only if the total amount of the consolidation loan and
your other eligible student loans is less than $7,500.
PAYMENT ELIGIBILITY (CONTINUED)
Page 4 of 6
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)
LOAN ELIGIBILITY
Only Direct Loan Program loans that are not in default
are eligible for PSLF. Loans you received under the Federal
Family Education Loan (FFEL) Program, the Federal Perkins
Loan (Perkins Loan) Program, or any other student loan
program are not eligible for PSLF.
If you have FFEL Program or Perkins Loan Program loans,
you may consolidate them into a Direct Consolidation Loan
to take advantage of PSLF. However, payments made on
your FFEL Program or Perkins Loan Program loans before
you consolidated them, even if they were made under a
qualifying repayment plan, do not count as qualifying PSLF
payments. In addition, if you made qualifying payments on a
Direct Loan and then consolidate it into a Direct
Consolidation Loan, you must start over making qualifying
payments on the new Direct Consolidation Loan.
If you are planning to consolidate your FFEL Program or
Perkins Loan Program loans into a Direct Consolidation Loan
to take advantage of PSLF and do not have any Direct Loans,
do not submit this form until you have consolidated your
loans. The online application for Direct Consolidation Loans
contains a section that allows you to indicate that you are
consolidating your loans for PSLF. If you plan to consolidate
Perkins Loan Program loans, first understand that Perkins
Loan Program loans may be cancelled for certain types of
public service. If you consolidate a Perkins Loan Program
loan, you will no longer be eligible for Perkins cancellation.
The online application is available at StudentLoans.gov
. If
you don't know whether you have Direct Loans, go to
StudentAid.gov/login.
EMPLOYMENT ELIGIBILITY
To qualify for PSLF, you must be an employee of a
qualifying employer. An employee is someone who is hired
and paid by the employer. You may physically perform your
work at a qualifying or non-qualifying organization, as long
as you are an employee of a qualifying employer. If you are
working at the location of or with an organization under
contract with your employer, the organization that hired
and pays you must be a qualifying employer, not the
organization where you perform your work.
A qualifying organization is a government organization, a
tax-exempt organization under Section 501(c)(3) of the
Internal Revenue Code, or a private not-for-profit
organization that provides certain public services. Service in
an AmeriCorps or Peace Corps position is also qualifying
employment.
EMPLOYMENT ELIGIBILITY (CONTINUED)
A private not-for-profit organization that is not a tax-
exempt organization under Section 501(c)(3) of the IRC may
be a qualifying organization if it provides certain specified
public services. These services include emergency
management, military service, public safety, or law
enforcement services; public health services; public
education or public library services; school library and other
school-based services; public interest legal services; early
childhood education; public service for individuals with
disabilities and the elderly. The organization must not be a
business organized for profit, a labor union, or a partisan
political organization.
Employment as a member of the U.S. Congress is not
qualifying employment.
You must be employed full-time by your employer.
Generally, you must meet your employer's definition of
full-time. However, for PSLF purposes, that definition must
be at least an annual average of 30 hours per week. For
purposes of the full-time requirement, your qualifying
employment at a 501(c)(3) organization or a not-for-profit
organization does not include time spent participating in
religious instruction, worship services, or any form of
proselytizing.
If you are a teacher or in another position under contract
for at least eight out of 12 months, you meet the full-time
standard if you work an average of at least 30 hours per
week during the contractual period and receive credit by
your employer for a full year's worth of employment.
If you are employed in more than one qualifying part-
time job simultaneously, you may meet the full-time
employment requirement if you work a combined average
of at least 30 hours per week with your employers.
Vacation or leave time provided by the employer or leave
taken for a condition that is a qualifying reason for leave
under the Family and Medical Leave Act of 1993, 29, U.S.C.
2612(a)(1) and (3) is equivalent to hours worked in qualifying
employment.
OTHER IMPORTANT INFORMATION
If you submit this form and your employer qualifies, all of
your loans held by the Department will be transferred to
FedLoan Servicing. FedLoan Servicing will then determine
how many qualifying payments you made during the period
of qualifying employment within the dates provided in
Section 3.
You are not permitted to apply the same period of
service to receive PSLF and the Teacher Loan Forgiveness
and Civil Legal Assistance Attorney Student Loan
Repayment programs.
Page 5 of 6
SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C.
552a) requires that the following notice be provided to you:
The authorities for collecting the requested information
from and about you are §421 et seq., §451 et seq., or §461 of
the Higher Education Act of 1965, as amended (20 U.S.C.
1071 et seq., 20 U.S.C. 1087a et seq., or 20 U.S.C. 1087aa et
seq.) and the authorities for collecting and using your Social
Security Number (SSN) are §§428B(f) and 484(a)(4) of the
HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C.
7701(b). Participating in the William D. Ford Federal Direct
Loan (Direct Loan) Program, Federal Family Education Loan
(FFEL) Program, or Federal Perkins Loan (Perkins Loan)
Program and giving us your SSN are voluntary, but you must
provide the requested information, including your SSN, to
participate.
The principal purposes for collecting the information on
this form, including your SSN, are to verify your identity, to
determine your eligibility to receive a loan or a benefit on a
loan (such as a deferment, forbearance, discharge, or
forgiveness) under the Direct Loan, FFEL, or Federal Perkins
Loan Programs, to permit the servicing of your loans, and, if
it becomes necessary, to locate you and to collect and
report on your loans if your loans become delinquent or
default. We also use your SSN as an account identifier and to
permit you to access your account information
electronically.
The information in your file may be disclosed, on a case-
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the
appropriate systems of records notices. The routine uses of
this information include, but are not limited to, its disclosure
to federal, state, or local agencies, to private parties such as
relatives, present and former employers, business and
personal associates, to consumer reporting agencies, to
financial and educational institutions, and to guaranty
agencies in order to verify your identity, to determine your
eligibility to receive a loan or a benefit on a loan, to permit
the servicing or collection of your loans, to enforce the
terms of the loans, to investigate possible fraud and to verify
compliance with federal student financial aid program
regulations, or to locate you if you become delinquent in
your loan payments or if you default. To provide default rate
calculations, disclosures may be made to guaranty agencies,
to financial and educational institutions, or to state
agencies. To provide financial aid history information,
disclosures may be made to educational institutions.
To assist program administrators with tracking refunds
and cancellations, disclosures may be made to guaranty
agencies, to financial and educational institutions, or to
federal or state agencies. To provide a standardized method
for educational institutions to efficiently submit student
enrollment statuses, disclosures may be made to guaranty
agencies or to financial and educational institutions. To
counsel you in repayment efforts, disclosures may be made
to guaranty agencies, to financial and educational
institutions, or to federal, state, or local agencies.
In the event of litigation, we may send records to the
Department of Justice, a court, adjudicative body, counsel,
party, or witness if the disclosure is relevant and necessary
to the litigation. If this information, either alone or with
other information, indicates a potential violation of law, we
may send it to the appropriate authority for action. We may
send information to members of Congress if you ask them
to help you with federal student aid questions. In
circumstances involving employment complaints,
grievances, or disciplinary actions, we may disclose relevant
records to adjudicate or investigate the issues. If provided
for by a collective bargaining agreement, we may disclose
records to a labor organization recognized under 5 U.S.C.
Chapter 71. Disclosures may be made to our contractors for
the purpose of performing any programmatic function that
requires disclosure of records. Before making any such
disclosure, we will require the contractor to maintain Privacy
Act safeguards. Disclosures may also be made to qualified
researchers under Privacy Act safeguards.
Paperwork Reduction Notice. According to the
Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless such
collection displays a valid OMB control number. The valid
OMB control number for this information collection is
1845-0110. Public reporting burden for this collection of
information is estimated to average 30 minutes per
response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the
collection of information. The obligation to respond to this
collection is required to obtain a benefit in accordance with
34 CFR 685.219. If you have comments or concerns
regarding the status of your individual submission of this
form, please contact your loan holder directly (see Section
7).
Page 6 of 6
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Public Service Employment Certification Form (South Puget Sound Community College)

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